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HIV Epidemiology amongHIV Epidemiology amongConflict-affected andConflict-affected and
Displaced PopulationsDisplaced Populations
Paul Spiegel MD,MPH
United Nations High Commissioner
for Refugees
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Mock NB, Duale S, Brown LF, et al. Conflict and HIV: A framework for risk assessment to prevent HIV in conflict-affected settings in Africa. Emerg Themes Epidemiol 2004;1(1):6.
Overlap between HIV and ConflictOverlap between HIV and Conflict
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HIV Prevalence by Asylum Country HIV Prevalence by Asylum Country and Country of Origin by Regionand Country of Origin by Region
0
1
2
3
4
5
6
7
HIV
pre
vale
nce
*
Africa (N=29) Asia (N=17)
Region**
Country of Asylum
Country of Origin
* Weighted means: country of asylum by population size, country of origin by refugee population size
** N refers to countries of asylum with >10,000 refugees
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HIV Prev. of Refugees and Host Communities HIV Prev. of Refugees and Host Communities in Selected Sites, 1998-2005in Selected Sites, 1998-2005
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HIV Prevalence in N. Uganda vs. HIV Prevalence in N. Uganda vs. National Data and Other Selected Sites*National Data and Other Selected Sites*
0
5
10
15
20
25
30
35
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
HIV
pre
va
len
ce
(%
)
Gulu
Moyo
Arua
Kitgum
Pader
National
Mbarara
Kampala
* For the Northern Uganda sites, Gulu, Moyo, and Arua used ANC data,20 while Kitgum and Pader use prevention of mother-to-child transmission programme data with acceptance rates by pregnant women of >97%;54 the non-Northern Ugandan sites of Kampala and Mbarara used ANC data)
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• Reduction in mobility• Reduction in accessibility• Slowing down of
urbanisation• Increase in resources and
services in host country
HIV Risk Factors for HIV Risk Factors for Conflict-Affected PopulationsConflict-Affected Populations
• Behavioural change• Gender violence/
transactional sex• Reduction in resources
and services (e.g. health, education, community services, protection, food)
• Area of origin HIV prevalence• Surrounding host population (pop.) HIV prevalence
• Level of interaction bw DP and surr. host pop.• Type and location of DP env. (e.g. urban vs. camp)
• Phase of emergency• Length of time: conflict, existence of camp
Increased Risk Decreased Risk
Key Factors
Modified from Spiegel PB. HIV/AIDS among Conflict-affected and Displaced Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):322-39.
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Behavioural Surveillance Survey (BSS) Behavioural Surveillance Survey (BSS) Study: Objective and MethodologyStudy: Objective and Methodology
• To evaluate quality of BSS in HEs and post-conflict situations and provide recommendations to NGOs and Gov'ts on how to improve quality
• 31 BSS evaluated between 1998-2005 in 14 countries classified as reproducible if pop. based sampling:
– Defined sampling frame– Used probabilistic sampling (incl. PPS
for cluster sampling)
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ResultsResults • Settings
– Conflict: 8 (25.8%)– Post-conflict: 9 (29.0%)– Refugee settings 14 (45.2%)
• Organisations– NGOs 23 (74.2%)– CDC 4 (12.9%)– UN agencies 3 (9.7%)– Gov’ts 1 (3.2%)
• Sample size – Mean: 1,261, median: 549, range: 148-7,484
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Results contResults contSampling Method Frequency (%)
Random sampling 23 (74.2)
Convenience 4 (12.9)
Not mentioned 4 (12.9)
31 (100)
If random what type? Simple random 4 (17.4)
Systematic 7 (30.4)
Cluster sampling 8 (34.8)
Not mentioned 4 (17.4)
23 (100)
All eligible person in hhold surveyed
yes 31 (100)
Sampling Frame yes 23 (74.2)
Reproducible yes 14 (45.2)
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Behavioural Surveillance Surveys Behavioural Surveillance Surveys (BSS) for Displaced Persons (DP) (BSS) for Displaced Persons (DP)
and Host Communitiesand Host Communities
• Modified questionnaire incl. pre-displacement, displacement and post-displacement/interaction modules with strong gender-based violence component developed*
• Undertaken in both DP and host communities• Development of BSS manual to improve quality
of BSS undertaken in field
* UNHCR, World Bank (GAMET), CDC, FHI and IRC
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ConclusionsConclusions• Complex relationship between HIV and conflict
– Findings not support contention that conflict increases HIV transmission regardless of magnitude of prev. when conflict began
– Refugees had lower or similar prev. than surr. pop.– Analysis is context-specific and no assumptions
should be made
• Need to examine (and program for) interactions between DPs and host pop. as well as returnees and those persons in area of return
• Need for improved biological and behav. data• Data can and should be used for advocacy and
programming purposes